Home Health & Hospice Week

Hospices should brace for even more scrutiny of their claims for long-stay patients.

Why? A hospice topic approved by the Centers for Medicare & Medicaid Services in October 2023 has shown up on Recovery Audit Contractor Performant’s approved topic list as a “nationwide” issue.

Under “Hospice Care- Extended Length of Stay: Medical Necessity and Documentation Requirements,” Performant says its review “will determine if billed Hospice Care with Extended Lengths of Stay was reasonable and necessary.”

Hospice claims that “do not meet the indications of coverage and/or medical necessity will be denied and result in an overpayment,” Performant adds.

The RAC lists affected codes as:

• 0651- Routine Home Care
• 0652- Continuous Home Care
• 0655- Inpatient Respite Care
• 0656- General Inpatient Care.

However, Performant fails to define what constitutes an “extended length of stay” for the probe.

“Generally, CMS considers extended lengths of stay to be 181-plus days of hospice care,” observes the National Association for Home Care & Hospice. “But NAHC is seeking clarification of the exact definition for this Issue,” the trade group says.

Performant does specify that the maximum its review can reach back is three years before the Additional Development Request (ADR) date.

This is the third-ever hospice topic approved for RAC review, NAHC points out. In 2021, CMS approved “Hospice Continuous Home Care” (see HHHW by AAPC, Vol. XXX, No. 8) and last year, CMS approved “Hospice General Inpatient Care.” The HHS Office of Inspector General added GIP audits as a Work Plan topic last June as well (see HHHW by AAPC, Vol. XXXII, No. 23).

Related: While not a direct hospice topic, CMS did approve “Durable Medical Equipment Billed during Hospice Period: Unbundling” as a RAC topic back in 2018 too.

In contrast, CMS has approved only one direct topic for home health agencies, the broad “Home Health: Medical Necessity and Documentation Requirements” back in 2017. But home health has had two unbundling topics approved as well, one for outpatient therapy in 2019 and one for consol­idated billing medical supplies last June.

The lion’s share of the scrutiny seems to be falling on hospices. “The RAC attention on hospice is consistent with CMS’ focus on hospice program integrity,” NAHC observes.

Note: CMS’ approved RAC audit topics are at www.cms.gov/data-research/monitoring-programs/medicare-fee-service-compliance-programs/medicare-fee-service-recovery-audit-program/approved-rac-topics — search for “hospice” or “home health” in the “Filter On” box. Performant’s list of audit topics is at www.performantcorp.com/cms-rac/cms-rac-resources/cms-approved-audit-issues.